Icd 10 coding and long term care whitepaper

ICD-10 Coding and Long-Term Care W H I T E PA P E R The following Q&A was adapted from HCPro’s “ICD-10 Coding and Documentation for Long-Term Care” webcast, presented by Karen Fabrizio, RHIA, CHTS-CP, CPRA, an AHIMA-approved ICD-10-CM/PCS trainer and a professor of health information and technology at Onondaga Community College in Syracuse, N.Y. For more information on this webcast, originally presented on February 5, 2014, visit http://hcmarketplace.com/coding-and-documentation-for-longterm-care or call customer service at 800-650-6787.

Q

What if you have multiple ulcers on the same site, such as two pressure ulcers on the right buttock? Both are a stage 2. Is there

a way to code both ulcers?

A

No. Unfortunately, ICD-10 only allows us to use a code once. You will need to make a notation that you’re applying one code to rep-

resent the two conditions, and then as one heals, or one worsens, you’ll be able to code the two additional codes. That is one of the downfalls of ICD10, but it was also present in ICD-9: We were not able to repeat codes.

Q

The RAI manual states that we are not allowed to reverse-stage pressure ulcers. Shouldn’t we keep the same ICD-10 code until

the ulcer is healed rather than changing the code? I do understand that the code would be changed if the ulcer worsens.

A

Yes, and this is currently being addressed by the Coding Clinic as it relates to long-term care. When the Coding Clinics were being devel-

oped, they were geared for acute care facilities. The question that results is where is that code going to be assigned? If you’re doing physician billing for a surgical consult, or physician billing for your physician visits, or billing for Part B billing, you’re going to want to represent the current and accurate stage for those billing processes. So while you’re staging for the MDS, you’re correct. You shouldn’t be back-staging according to the RAI, but this is where billing may not always match that. Stay tuned; there should be more clarification coming on that.

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ICD-10 CODING AND LONG-TERM CARE

Q

March 2014

Are there any guidelines or lists of ICD-10 codes for PT, OT, and ST treatment? If so, where can we find those?

A

There are no specific guidelines for the diagnoses. The ICD-10-PCS, the Procedure Classification System, does have some guidelines for the procedure coding, but we’re not going to be using those in long-term care. We’re still going to be using the HCPCS code. Unfortunately, there are no guidelines for those types of treatments, but what you can do is take a look at the treatments that your therapist is currently providing and think about the neuromuscular conditions related to those treatments. You may be able to develop a cheat sheet of those specific codes and then look at them and decide as a group, how you are going to be assigning those codes.

Q

Are you saying that coders can use or need to use documentation that the nurse has done? I am asking because you are saying to add these things to our documentation forms.

A

There are certain areas where you need to make sure your documentation is consistent. As you are sending records out for review by Medicare or the managed care organization, it’s possible that in the dates they requested that there is no physician documentation, so your nursing documentation may be the only documentation available. You want to make sure that everything is consistent. The coding guidelines do say specifically for pressure ulcers that you can go directly to the nursing documentation and get that diagnosis or stage. Your physician has to state that the patient has a present ulcer, but you can get the stage from nursing. As we are releasing records and sending them out, we have to be aware that if they’re looking at a snapshot of information and our physician hasn’t seen the patient in the last 45 days, that we include the supporting documentation within our nursing notes.

Q

If a fracture occurs in our facility and they are sent out and treated in the hospital, when they return are they considered subsequent care?

A

Yes, this would be considered subsequent care. But when you go to send them out, most facilities have a computerized admission transfer discharge system (ADT). When you go to transfer that patient out or discharge them out, your diagnosis is going to be needed. That is when you should code a current episode, represented with a 7th digit of an A. Then, when they return, you would code for subsequent care.

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March 2014

ICD-10 CODING AND LONG-TERM CARE ­3

Q

Will it be necessary to convert our residents’ current ICD-9 codes to ICD-10 codes?

A

Yes, when you bill for services as of October 1, you will not be able to supply or use ICD-9 codes. So if that claim is for October 1–4 and you have an ICD-9 code on it, that claim is going to be rejected. MS and all of our major insurance carriers have said they will reject it. There will be no grace period. That’s really important. The other thing you need to be mindful of is if you have a physician order entry system that sends lab rec requests automatically to your lab vendor or automatically to your radiology vendor, and you’re not having someone fax the order. Most CPOEs, as part of our meaningful use criteria, require a diagnosis. On October 1st you run the risk of that medication, or that requisition, not being able to be accepted or possible at the receiving end because it hasn’t been converted.

You will have to convert your codes. I recommend cleaning up your data.

If you haven’t gone through and validated that all of the current conditions for a resident are still current and accurate, it will make more work for yourself. Start looking at the diagnoses and identifying which ICD-9 codes are no longer present. You may find a fracture from 2012 still present; delete it. You may find that a patient came to you with a CVA that you coded as acute, and now you can code it in ICD-9 to a late effect. Clean up your data now. Clean up your codes.

Q

If a resident breaks a bone in our facility and goes to the hospital right away and is admitted to the hospital, how would we code the fracture when the resident returns?

A

You would put in your ADT system that they went out with a current fracture, and then when they return you would code it as a s­ ubsequent.

Q A

How do I indicate that the patient is s/p surgery (ORIF)? Do you need to include a code for aftercare following surgery?

You would not include a code for a patient who is coming to your facility as a result of aftercare for an injury. All of our injury codes, which also includes all of our poisoning, have a 7th digit that shows subsequent care. That’s why it’s important when you’re collecting your data for your fractures that everyone who is coming back in is coded for subsequent care. You’re no longer doing the current care. For this person, you wouldn’t code an aftercare; you’d use a subsequent 7th digit for aftercare.

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ICD-10 CODING AND LONG-TERM CARE

Q A

March 2014

What do you do when you don’t have enough information to code a diagnosis upon admission to the facility?

You can still query your physician and your hospital. If the patient is coming to you from the hospital, you can ask for more documentation. If the patient is coming to you as an admission from home, you can query their attending physician. Somewhere there is probably more information. We shouldn’t just take the statement of “diabetic”; we have to be able to delve down further. Turn to your medical records staff and ask them, or turn to your social workers and ask them to get the necessary information, and put it in your records.

Q A

For Med A residents, will we still use a therapy code (like V57.89 in ICD-9) as the primary diagnosis?

It all depends on why they’re coming in to your facility. If it’s following a cerebrovascular accident, the CVA has a seventh code that shows subsequent or late effect. The injuries have a late effect. A lot of the things that you use a V57.89 for have been replaced by the subsequent code. That’s where you have to look at the coding guidelines, and the guidelines are specific as to when you should use aftercare codes. They are Z codes now, no longer V, and they will give you guidelines as to when to use aftercare codes and when not to.

Q A

Sample case 3: Would PT/OT be coded as the primary diagnosis for that patient followed by the codes listed in the example?

There is no code for admission for PT/OT. You need to look at what they are receiving PT/OT for and code that. If it’s for an injury, you’d use a subsequent care code.

Q A

Will there be official coding guidelines issued for the longterm care setting?

There’s been speculation and requests for it, but there currently aren’t official coding guidelines for the long-term care setting.

Everything you see currently is an individual’s interpretation for how ICD codes are used in long-term care. One of the things the AHA (American Hospital Association) has said is that they recognize the scenarios differ from acute care to long-term care to outpatient care. Their goal is to identify the areas that are different, like the fractures we’ve discussed, but there has been no definitive timeline established for that.

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March 2014

ICD-10 CODING AND LONG-TERM CARE ­5

Q A

How often should codes be updated? As something resolves/ changes?

That’s a question that will be different for every facility. What we did at our facility is to assign codes on admission, and then we review the codes when they come off Medicare. The majority of our patients come in on Medicare. So, when they come off Medicare, and they were continuing to stay at our facility, we would look at their codes and their conditions, and reassign codes. Anytime there is a significant event, such as a hospital admission, it’s possible that when the resident comes back to us, we’re going to have new diagnoses. Every time you do an MDS, outside of the allowable 100 days for Medicare, every quarterly, every annual, every significant change, is a good time to be updating codes. Section I is where you can pick up those additional codes.

Q

When coding stages for a pressure ulcer, do we continue coding as a resolving PU at same level or an improving PU at lower level? How does this affect MDS versus billing?

A

You still need to follow your MDS rules. For billing, the code that you’re going to be putting on your claim will show that an individual has a pressure ulcer or multiple pressure ulcers and at what stage.

Sometimes there are MDS nurses coding, and we need to be able to separate and segregate those codes. When you’re submitting a claim for the month of September, you’re submitting September’s claim, not just the claim for the MDS represented on September 15th. There could be some occasions where there are going to be discrepancies. That is where your coding policies come in and identify who, what, and why.

Q

What if the MDS was completed in September but that MDS affects billing in October? What codes do we put on the MDS: ICD-9 and/or ICD-10?

A

If you’re billing September’s claim associated with a September MDS, you will be using ICD-9. You may not realize this, but your facility has always had to split the claims when a resident crosses over from September 30th to October 1st because that is part of the fiscal year for Medicare. We actually have to submit two claims. Your September bill will use ICD-9 codes with the appropriate RUG codes, and your October claim will use ICD-10 codes with the appropriate RUG codes from your MDS in September. Right now there is no requirement that as of October 1 you have to do a new MDS. The MDS that you did in August and September will be allowed for use with October bills. You will only need to change the ICD-10 codes.

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ICD-10 CODING AND LONG-TERM CARE

Q A

March 2014

When do we code sequela?

Sequelas are used anytime there is a residual, and that is one of the things the coding guidelines updated. In the past, with ICD-9, we had to wait a year. Now, we can code that any time a resident is admitted to us with residuals. The fact that they are transferring from one level of acute care to another level of long-term care allows us to do that. As an example, if the patient had a CVA a week and a half ago and has that residual, such as hemiplegia or aphasia, identified at the time of discharge, we are now able to code that as a sequela when they come to us.

Q A

Are we going to change the space in the MDS form for ICD-10 coding in our software?

Your software company should be working on that right now. You should make sure your electronic medical record vendor can accept ICD-10 codes and that they are preparing for the changes in the MDS.

New on-site boot camp for 2014!

Compliant ICD-10-CM Coding and Documentation for LTC Introduce your nursing home staff to ICD-10 with this overview that highlights the biggest changes and how these changes will affect long-term care facilities. You will learn the difference between ICD-9 and ICD-10 codes, understand major changes to official coding guidelines, learn which common conditions and diseases will require additional information to code, and develop the confidence to tackle the new system.

After attending this boot camp, participants will be able to: ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

iscuss the issues related to the transition from ICD-9-CM to ICD-10-CM D Discuss the development of the ICD coding process Explain the impact of ICD coding on Medicare payment List examples of diagnoses that impact Medicare reimbursement in LTC Identify ICD-10-CM code structure Identify the major ICD-10-CM coding conventions Identify at least two general coding guidelines as they apply to long-term care patients Detail the nuances in the selection of principal diagnosis and/or first-listed conditions Identify ICD-10-CM chapter-specific coding guidelines that impact postacute care Apply coding guidelines for external causes of injuries Demonstrate the use of basic coding guidelines

For more information, or to schedule to bring this boot camp to your facility, please call 800-650-6787 or email bootcamps@hcpro.com.

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